198602936-9-16-2024-28-AS-ALOZ-D9728W-20240916171101

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602936
Report Date: 09/16/2024
Date Signed: 09/16/2024 05:11:07 PM

Document Has Been Signed on 09/16/2024 05:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	MY LADIES GUEST HOUSE		FACILITY NUMBER:	198602936
ADMINISTRATOR:	TILLMAN, GREG		FACILITY TYPE:	740
ADDRESS:	128 N FOURTH STREET		TELEPHONE:	(626) 863-6349
CITY:	ALHAMBRA	STATE: CA	ZIP CODE:	91801
CAPACITY:	15	CENSUS: 11	DATE:	09/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:18 PM
MET WITH:	Rosalie Ngo and Greg Tillman - Administrators		TIME COMPLETED:	05:23 PM

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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA Lopez met with Licensee Rosalie Ngo and explained the reason for the visit.

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan.

Operational Requirements:

A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for ten (10) resident is approved.

Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. A surety bond is not applicable. Facility does not handle resident's money.

Physical Plant/Environment Safety:

Facility is in good repair indoor and outdoor. Kitchen is clean, refrigerator and freezer are in good repair. Sufficient food was observed for at least 2 days of perishables and 7 days of non-perishables. Sharps and medication are kept in the kitchen. Residents do not have access to the kitchen. Each resident's room (8) were observed with sufficient lighting, required furniture, and bedding supplies. Room #3 is being used by staff and room #4 is being used as a storage. Each bathroom (7) was observed in working condition, grab bars and skid mats were observed, and water temperature was tested between 110.3-118.4 degrees F., which is within the required 105-120 degrees F. Cleaning supplies are kept in a lock closet in the hallway. Additional bedding supplies were observed. First aid is available with all the required items. Living room, dining room, and family room are clean and have sufficient seating space.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MY LADIES GUEST HOUSE	FACILITY NUMBER: 198602936
	VISIT DATE: 09/16/2024

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Motion sound detector device was observed in the front door, door going to the laundry, and gate in the side patio. Facility is currently serving 2 residents with dementia. Cameras were observed in the common areas. Carbon Monoxide/Smoke detectors were observed and in working condition. Fire extinguishers were last checked on 08/01/2024

Food Service:

Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.

Due to time constraints, LPA will return to complete inspection on a later day. Per California Code of Regulations, No deficiencies were cited today.

Exit interview was conducted with staff. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

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